STOPP/START Criteria and Safe Prescribing in Geriatrics

Comprehensive flashcards covering STOPP/START criteria, geriatric safe prescribing, clinical trial data outcomes, specific drug-risk exclusions, and ACIP vaccination schedules for older adults.

What is the primary purpose of the STOPP (Screening Tool of Older People’s Prescriptions) criteria?

To provide guidance on potentially inappropriate medications (PIMs) in older adults that are associated with adverse reactions.

What is the primary purpose of the START (Screening Tool to Alert to Right Treatment) criteria?

To identify potential prescribing omissions (PPO) of medications that should be recommended for elderly patients in the absence of a legitimate rationale.

How did the volume of the STOPP/START criteria change in the 2023 update?

The criteria increased from $114$ (2015 update) to $190$ (Summer 2023 update).

What clinical outcomes are associated with the application of STOPP/START criteria within $72$ hours of admission?

Significant reduction in ADRs (adverse drug reactions), a decrease in length of stay by $3$ days, and an absolute risk reduction of $9.3\%$ with an NNT of $11$.

How does the applicability of STOPP/START criteria differ from the Beers criteria?

STOPP/START is more applicable outside the US than Beers, includes START criteria (omissions) which Beers lacks, and includes resources for each recommendation.

According to STOPP criteria, why should loop diuretics be avoided for dependent ankle edema without evidence of heart or renal failure?

Leg elevation and/or compression hosiery are usually more appropriate for this condition.

Why does STOPP advise against using centrally-acting antihypertensives like methyldopa or clonidine in older adults?

They are generally less well tolerated by older people than younger people.

What is the STOPP recommendation for statins in primary cardiovascular prevention for patients aged $\ge 85$ with established frailty?

They should be avoided if life expectancy is likely less than $3$ years due to a lack of evidence of efficacy.

Why are SSRIs in combination with Vitamin K antagonists or factor Xa inhibitors flagged in STOPP for patients with a history of major hemorrhage?

There is an increased risk of bleeding due to the antiplatelet effects of SSRIs.

What is the STOPP concern regarding SNRI use in patients with severe hypertension ($SBP > 180\,mmHg$ or $DBP > 105\,mmHg$)?

SNRIs (e.g., venlafaxine, duloxetine) are likely to make the hypertension worse.

According to STOPP, what is the risk of using SSRIs in patients with serum $Na^+ < 130\,mmol/l$?

There is a risk of exacerbating or precipitating hyponatremia.

What is the maximum recommended duration for benzodiazepine use for insomnia according to STOPP criteria?

Less than $2$ weeks; use for $\ge 2$ weeks carries a high risk of dependency and increased risk of falls, fractures, and road traffic accidents.

Why should antipsychotics (other than clozapine or quetiapine) be avoided in patients with Parkinsonism or Dementia with Lewy Bodies?

There is a risk of severe extra-pyramidal symptoms.

What heart rate threshold is used by STOPP to flag Acetylcholinesterase inhibitors due to the risk of conduction failure?

A known history of persistent bradycardia ($< 60\,\text{beats/min}$).

What is the STOPP recommendation for Proton pump inhibitor (PPI) use in uncomplicated peptic ulcer disease?

Avoid full therapeutic dosage for $> 8$ weeks; dose reduction, discontinuation, or H2 antagonist maintenance is usually indicated.

Why is megestrol acetate noted as potentially inappropriate for increasing appetite?

It has unproven efficacy and is associated with an increased risk of thrombosis and death.

What is the risk of using systemic antimuscarinic drugs in patients with dementia or chronic cognitive impairment?

Risk of increased confusion and agitation.

Which medications are specifically grouped in STOPP Section K as drugs that predictably increase the risk of falls?

Benzodiazepines, Antipsychotic drugs, and Hypnotic Z-drugs (zopiclone, zolpidem, zaleplon).

What are the paracetamol dose limits for patients with a BMI $< 18$ or chronic liver disease according to STOPP?

Avoid doses $\ge 3\,g/24$ hours due to the risk of hepatotoxicity.

According to START, what is the blood pressure threshold for initiating antihypertensive therapy in older adults with moderate-to-severe physical frailty?

$150\,mmHg$ systolic pressure and/or $90\,mmHg$ diastolic pressure (compared to $140/90$ for non-frail patients).

What 25-hydroxycolecalciferol level indicates Vitamin D deficiency in older people who are housebound or experiencing falls?

$< 20\,micrograms/L$ (or $< 50\,nmol/L$).

Which geriatric-specific flu vaccines are recommended for a stronger immune response?

High dose (Fluzone) and Adjuvanted (Fluad).

For the Shingles vaccine (Shingrix), which older adults should receive it according to current guidance?

Adults $\ge 50$, even if they were previously vaccinated with Zostavax.

What is the pneumococcal vaccine recommendation for a geriatric patient with no known history or who has not received any previous doses?

$1$ dose of PCV20 or PCV21, OR $1$ dose of PCV15 followed by PPSV23 one year later.

How does the CDC define a health care provider in the context of Shared Clinical Decision-Making (SCDM)?

Anyone who provides or administers vaccines, including primary care physicians, specialists, physician assistants, nurse practitioners, registered nurses, and pharmacists.

What is the standard definition of polypharmacy in the geriatric population?

Typically defined as the concomitant use of $\ge 5$ medications.

What is the 'prescribing cascade'?

Occurs when clinicians prescribe new medications to address adverse drug reactions or side effects of existing drugs instead of adjusting the offending agent.

Define 'deprescribing'.

The removal of therapy when the benefit no longer outweighs the risk, it is harmful, or no longer indicated.